Health inspection·December 3, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON on 12/03/2025 at 4:18 p.m., said she had been trained on the MDS. She said the policy for the MDS was that the MDS had to be done within 14 days of admission. She said the MDS Nurse was responsible for completing the MDS. She said the MDS consisted of everything the resident does. She added the MDS covered the resident's cognitive level, and ADLs. She said a resident's contractures was also to be on the MDS. She said if a resident's contractures was not on the MDS then the facility would not capture the care and management for the resident. She said the MDS nurse would pull all the data from the nurses and the CNAs and making sure that information was correct. She said that she did not know why Resident #25's contractures was not on his MDS. During an interview with the ADM on 12/03/2025 at 4:40 p.m., said she had not been formally trained on the MDS. She said the MDS had to be done within 14 days of admission and quarterly there after depending on the resident's stay status. She said the MDS coordinator was responsible for completing the MDS. She said the MDS was a health assessment. She said the contractures should be on the MDS if the contracture affects a resident's range of motion. She said the if the contractures did not affect the resident's range of motion it did not have to be on the MDS. She said that MDS nurse monitors to ensure the MDS was correct. She said she monitored the MDS by using a tool on the computer to scan for errors. She said Resident #25's contractures did not need to be on the MDS because he was dependent on staff and Resident #25 did not complete any part of his ADLs. Record review of MDS 3.0 Completion policy not dated revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. Residents are assessed by using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Care Area Assessment (CAA's): i. The CAA process outlined in Chapter 4 of the RAI manual is designed to assist the assessor in systematically interpreting the information recorded on the MDS to facilitate decision making regarding the resident's plan of care. ii. There are 20 CAAs. The responsibility for completion of each CAA will be clearly assigned. See CAA and Care Plan Division of Responsibility - Expectation List supplemental document. iii. Written documentation of the CAA findings and decision-making process may appear anywhere in the resident's record. iv. The signature of the Person Completing Care Planning Decision can be any designated member of the care plan team or persons who facilitate the care planning decision-making process. Record review of the RAI [NAME] dated 10/2025 revealed You must determine whether the limited ROM has an impact on functional ability or places the resident at risk for injury. Coding Instructions for GG0115A: Functional Limitation in Range of Motion Upper Extremity (Shoulder, Elbow, Wrist, Hand); GG0115B, Lower Extremity (Hip, Knee, Ankle, Foot)Code 0, no impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper- and/or lower-extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. Code 2, impairment on both sides: if resident has an upper- and/or lower extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injury. Event ID: Facility ID: 676099 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbour at Westminster Manor 4200 Jackson Ave Austin, TX 78731 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to seal the food in the freezer. The facility failed to ensure that items were labeled and dated in the freezer. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. An observation made on 12/01/2025 at 9:00 AM, of the walk-in freezer revealed food boxes stored on top of crates, unlabeled unidentified food items, and there was food opened in a bag that was not sealed, and the food was exposed to the air. An observation made on 12/01/2025 at 1:30 PM, revealed a variety of packaged food was still on the crate inside the walk-in freezer. An observation made on 12/02/2025 at 10:40 AM, revealed new unidentified food boxes inside the walk-in refrigerator on the floor and walk in freezer on the floor. During the observation, the opened unlabeled food items were still opened inside the freezer. An interview conducted on 12/03/2025 at 11:57 AM, with the DM revealed that they had been employed at the facility for 7 years. The DM stated that the policy on food storage is food should be stored in a safe manner. The DM stated that food should be labeled and dated after opening. The DM stated that all the food should be in containers, if needed and covered. The DM stated that for food for shelving should be at least 6 inches from the ground. The DM stated that food should never be placed on the ground even if it is in the package. The DM stated that it could negatively affect residents by potentially causing food borne illnesses and contact with unclean surfaces. An interview made on 12/03/2025 at 1:15 PM, with CK A revealed that they had been employed at the facility for 1.5 years. CK A stated food should be closed and if food was opened in a bag, it should be closed because it is considered an open container. CK A stated that the food should be closed because the expiration date automatically starts when the item is open. CK A stated food staff should follow procedures.An interview made on 12/03/2025 at 2:00 PM, with SC revealed that they had been employed at the facility for 7 years. SC stated that after food deliveries that are done Monday through Friday, the food should be put away. SC stated that the food would come off the truck and put in the respective areas in the kitchen. SC stated that the policy for food receiving was to put the food away right when the facility received it. SC stated the staff do not store food on the floor. SC stated when food is inside of a bag, the bag should be wrapped back up before they close the box. SC stated not closing the bag could result in frost burn, flavor loss and color loss. SC stated it could negatively affect a resident by psychologically off putting. An interview made on 12/03/2025 at 4:24 PM, with the DON revealed that they had been DON at the facility for 3 months. The DON stated food that had been left uncovered and sealed may cause resident harm. The DON stated that the standard was for the staff to close the products that they used when they were done with it. An interview made on 12/03/2025 at 4:48 PM, with the ADM revealed that the ADM had been employed at the facility for 6 years. The ADM stated the policy for kitchen storage was when staff received the food delivery, the food should go straight to the fridge or freezer. The ADM stated food could be placed on the floor when it was delivered. The ADM stated that placing the food on the floor in its assembled box could not affect the quality of the food. The ADM said it would not affect residents. The ADM stated the policy for food exposure would be to discard the food that was left open. The ADM stated she does not know what type of harm could arise for residents if food was exposed to the air. The ADM stated the expectation for food bags is to ensure they are closed when staff are done using the food. The ADM stated that food should be labeled when they arrive to the facility and should follow facility policy regarding that. Record review of a document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676099 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbour at Westminster Manor 4200 Jackson Ave Austin, TX 78731 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete provided by the facility titled Policy & Procedure Manual Delivery Schedule dated 2023 revealed the following:1. Deliveries are accepted 7 days a week. Record review of a document provided by the facility titled Policy & Procedure Manual Food Storage dated 2023 revealed the following:1. All food items should be stored upon delivery and careful rotation procedures should be.followed.2. All foods should be stored off the floor.3. All foods should be covered, labeled, and dated. All foods will be checked to ensure that.foods will be consumed by their use by dates or discarded. 4. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. Event ID: Facility ID: 676099 If continuation sheet Page 4 of 4